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Next Steps in Public Health
NEXT STEPS IN PUBLIC HEALTH By T h o m a s P a r r a n , J r . , M.D., Washington, D. C. Surgeon General, U. S. Public Health Service Edm und,
Earl
of
D erby,
who
dyed
in
Q ueen Elizabeth’s days, was famous for chirurgerie, bonesetting, and hospitalitie.
O records the diary of John Ward, a seventeenth century vicar of Stratford-on-Avon. That phrase with its medical flavor has an aptitude for this gathering. There is, in the first place, the warm hospitality of your welcome and my own personal friendship with many of you. But there is, beyond that, the warmth and hospitality which have marked all the relations of the American Dental Association with the United States Public Health Service. There is no group with which we have worked more happily than with yours. Yours were among the strongest shoulders put to the legislative wheel a few years ago when the Public Health Service was reor ganized on more effective lines. Your ac tive interest in the preventive aspects of your medical specialty places your philos ophy particularly close to that of those who work in public health. You have co operated with us actively in numerous studies and investigations. In the Public Health Service, the dental surgeon works in his rightful place as a commissioned officer with status equal and identical in every way to that of his medical and engi neering colleagues. I would emphasize that status of colleagueship. It was once customary, I be lieve, for a physician addressing a group of dentists to begin his remarks with a reference to Paul Revere. The reference was not to that gripping night when Paul peered through the mouth of the Charles
S
(Read at the Second General M eeting o f the Seventy-Ninth Annual Session of the American Dental Association, Atlantic City, N . J., July 13, I937-)
Jour. A .D .A . & D. Cos., V o l. 24, November 19 3 7
River to discover whether one or two of the cavities in the North Church tower would glow with gold, but to those later days when he was a dentist to the Boston brahmins and member of Boston’s first board of health. It was a good beginning for a physician. It gave him self-confidence before your profession. It served to remind him and his audience that medicine is a senior branch and that dentistry began as an in cident to other trades. And I shall not gainsay that many required confidence. For, as Dr. Oliver Wendell Holmes told Harvard’s first dental graduates, yours is “a profession in whose presence kings are silent, at whose command eloquence is struck dumb, and even the irresistible and irrepressible voice of woman is hushed in a brief interval of repose.” The physician, of course, in using the historical allusion was wont to ignore the fact that medicine, too, was once a child. Paul Revere and the Egyptians may have built their bridges with no thought of pathology. They may not have under stood the problem of decay or the minute organisms that are the parents of infec tion; but neither did the doctors of the day whose work as physicians had but re cently been divorced from other trades. “In King Richard the Second’s time, phy sicians and divines were not distinct pro fessions,” said that same John Ward. It had been but a century or so before Re vere that the physician and the barber went different but equally unscientific ways. The man who inserted an inlay without thought of an abscess was little different from the man who sutured a wound without knowledge of microbes. If John Greenwood, who constructed the I 778
Parran—Next Steps in Public Health
ivory, spring-controlled teeth of George Washington, was only an artificer, the doctors who bled him repeatedly till the “blood came slow and thick” leave even less for the admiration of posterity. Yes, if dentistry rode with Paul Revere in the past, the candid reader cannot escape the fact that medicine rode frequently with the fourth horseman. But I did not come to discuss history. Both medicine and dentistry are emerging froma past which, while earnest and hon orable, was frequently unscientific. Even now, we have done little more than scratch the surface of potential knowl edge. There is much unfinished business, in our sciences if we are to prolong life, to promote health and to add to the total of human happiness and prosperity. Our emphasis is shifting from cure, from alleviation of symptoms to prevention. Diseases of the teeth present one of the most promising fields for a program of prevention. It has been estimated that but a quarter of our population now re ceive adequate dental care. Tooth ail ments are next only to the common cold as the most frequent of our ills. Dentists over a period of two decades have most effectively impressed their pa tients with the need for regular care. The American who does not have his dental examination two or three times a year is apologetic; whereas, the American who never has a thorough general physicial examination all too frequently regards his lapse from medical observation as a sign of masculinity or strength. You have, without doubt, a strong cos metic urge as your ally in interesting the public in teeth. “There is no pearl in any royal crown for which a young queen would give one of her front incisors,” said Holmes. It is an advantage in propa ganda the physician does not have. If our hearts were, indeed, worn on our sleeves, one may suppose that heart disease would appear earlier for diagnosis. But what ever the reason for public consciousness of teeth, the result is there. Your patients
1779
come back. Your profession recognizes a responsibility on the part of the practi tioner to invite them to the periodic ex amination. R ELATIO N O F T H E P U B LIC H E A L T H SE R V IC E TO D EN T IST R Y
*
The work of the United States Public Health Service with relation to dentistry falls into a natural trichotomy. There is first the clinical work, the furnishing of dental service. There is, secondly, the public health work, the development of a program which will reduce the incidence of dental disease and bring existing dental disease to diagnosis and treatment. There is, finally, the extension of our knowledge of dental ill health through scientific re search. I shall consider themsuccessively. T R E A TM EN T
Treatment is furnished only to bene ficiaries of the United States Public Health Service. This includes merchant seamen, and the Coast Guard, who have been medical charges of the Service since its establishment in 1798. It includes lepers, those held at immigrant stations, inmates of federal penitentiaries and a few special groups. Full-time officers of the Service gave 698,743 treatments to 173,271 patients during the year 1936. We have taken the attitude that care of the patients in our charge involves skilled dental care no less than competent diag nosis and treatment are required in the other specialties of medicine. P U B LIC H E A L T H
One could not epitomize the change that has taken place in dentistry during the past sixty-five years more succinctly than by contrasting that previously cited Harvard commencement address of Dr. Holmes with the discussion in the den tal journals today. It was the mechanical wonders of replacement that enraptured the dentist in 1872. He drew an urbane contrast between the rateliers of the French and the “mineral teeth” which
1780
The Journal of the American Dental Association and The Dental Cosmos
America had brought to “greatest per fection.” “There are nine factories en gaged in their fabrication,” he boasted. “Compare the delicately tinted, exquisitely shaped porcelain incisors with those frightful palisades that used to play up and down like a portcullis in a manner terrifying to all beholders.” The modern emphasis on saving teeth, the fact that teeth have utilitarian uses essential to the health and happiness of the human animal, is hinted at only one point. Holmes quoted the sad complaint of Wal ter Savage Landor: “I have lost my mind,” cried the poet; “that I do not care so much about; but I have lost my teeth and I cannot eat.” Today, dentists fight to save teeth and to develop sound teeth. Health depart ments and school health services are or* ganized to ascertain the condition of children’s teeth and to give them prophy lactic care. Industrial medical services find that a dental clinic pays dividends in time saved and in increased efficiency. Not cosmetics, but economics has pre sented its brief for better dental care. It was the Social Security program which crystallized our economic interest in the public health. One must go back a little in history to trace that develop ment. When the President appointed a committee to consider ways and means of minimizing social insecurity, it was evi dent that the problem of preventable un employment and preventable disability due to disease were keys to the ultimate stability of the program. The late Edgar Sydenstricker headed the technical committee which dealt with medical care. Any national program of health security, he declared, should em phasize prevention of disease, and preven tion should take precedence over any efforts to distribute the costs of sickness or its consequences. From his recommendations grew those provisions of the act which relate to pub lic health. An appropriation of $8,000,000 a year was provided to assist states
and counties and other political subdi visions in establishing and maintaining adequate public health services, including the training of personnel. These funds are distributed among the states on a three fold basis: The population of the states, the special health problems of the state and the financial needs and resources. An additional $2,000,000 was authorized to extend the research work of the Pub lic Health Service. The precise programs in each state are not under any authoritative control of the United States Public Health Service or any federal agency. The act provides that before the regulations are issued govern ing the state allotments, conferences should be held with the states and terri torial health officers. These regulations apply with equal force to the dental pub lic health program and to all other public health developments under the act. The first conference of state health officers in 1935 drew up regulations as to the pur poses for which such funds might be ex pended. As I see it, the United States Public Health Service can exercise its best influ ence over this development by acting as a catalytic agent, bringing together, stimu lating into action, local public and private agencies throughout the land. It can re port facts; it can synthesize the work of others; it can operate the lighthouse on which local public health navigation must depend. I would dwell briefly on some of our recent work. Foremost, perhaps, is the work of oral health education. Dr. Frank C. Cady, dental surgeon of the Service, has recently prepared an outline of procedures in this field for the assistance of health officers and local groups. These are the principles which he emphasizes: That the dentist administering this activity for the health department have graduate training in public health methods; that his work shall be directed toward stimulatingand coordi nating the work of all agencies and indi viduals concerned : the dental profession,
Parran—Next Steps in Public Health
the medical profession, public health nurses, school teachers and those who will benefit from the program: the pre-school children, the school children and the adults of the community. There are two points which are empha sized in the contemplation of the Social Security Act. One is the local control over the development of the program. The other is that personnel shall be trained and high professional standards be main tained in order that local control may be thoroughly effective. In dealing with all groups who work under the Act, the Public Health Service seeks to develop the technics that will insure the success of that local control, and thus cooperation with the dental societies and the medical socie ties in coordinating the work is urged in considerable detail. In every state health department, there should be a dental division, and this divi sion should be charged with responsibility for developing this program. That was the recommendation of the Conference of Local and State Health Officers. Many states have established such offices. To meet the need for trained personnel, short intensive courses are being set up to train health officers, nurses and other personnel in the problems of the new program. Cer tain schools were designated as regional training centers by a majority vote of state health officers. They were selected for their special facilities for dealing with public health matters. The ultimate success of training and planning, however, must rest upon the completeness of our facts. Measurement must precede the draftsman’s pen. As to dental needs, we have such facts. Last year, the Public Health Service published a dental survey of school children, ages six to fourteen years, made in 1933-1934 under the direction of the late Dr. C. T. Messner. Data for tabulation were con tributed by more than 8,000 practicing dentists in twenty-six states. The published report of Dr. Messner’s survey is no light reading. It is nothing
1781
to read in the nonchalant comfort of a lounge chair. Of its 248 pages, 277 are the tabulated record of the findings of the 8,000 of your colleagues who examined the teeth of the school children in the twenty-six states surveyed. It is a record of dental caries in American school chil dren, of gingivitis, of extractions needed, of malocclusion. With its figures—and you can request it as Public Health Bulle tin No. 226—this survey provides state health authorities and your local societies with the ammunition for a campaign for better dental care. You will find it there county by county and town by town as a factual basis for needed action. R ESE A R C H
Salient in the fight against dental dis ease is the third field of our concern, re search. We must discover the causes of dental caries, we must find the factors in building sound and regular teeth and the things which will inhibit diseases of the teeth. Research has all too often been given over to the great dramatic things which kill and maim a few, while the things which sap the vitality of the million are ignored. As a consequence, tooth diseases which are merely common are not so well un derstood as they must be if we are to make real progress in reducing their incidence. It is in the field of research that the Pub lic Health Service can contribute a great deal to the dental profession. In research and as a clearing house for research, the Service makes one of its greatest contribu tions. One such project has already pro gressed to the point where it has produced results. You are, no doubt, familiar with the studies which H. Trendley Dean, den tal surgeon, has conducted in the problem of mottled enamel. The Service published in 1933 his study on the distribution of mottled enamel in the United States, which localized sixty-seven areas of high prevalence. The following year a report of laboratory experiments which showed the
1782
The Journal of the American Dental Association and The Dental Cosmos
effect of ingestion of various amounts of sodium fluoride on the teeth of white rats was published. Studies since that time in the special area of Texas and in the minimal threshold of mottled enamel have added to the accuracy of our knowl edge. These and the various experiments in the field of nutrition suggest that dental research may open new vistas in the chemical interpretation of human ills. There is one point to which I think your profession and this association should direct special attention. That is the funds for research. The amount of research which may be done will be limited, is bound to be limited, by the funds which are available. For dental diseases which are persistent rather than deadly, appro priating bodies have not always seen the wisdom of supplying funds for research. I hope it will be possible for the United States Public Health Service to extend its work with your research committees in stimulating and assisting research in uni versities and scientific institutions. We need, then, to extend our knowl edge of the factors which make for dental health. Hand in hand with this search for new knowledge must go the better appli cation of present knowledge, first to pre vent disease, and secondly to give needed care and treatment to all groups of the population. Each dentist needs to concern himself not only with the dental needs of the individual patient, but also with the dental needs of the whole community. Dentistry of today differs a great deal from that of Paul Revere’s day. Scien tifically it has evolved as the result of suc cessive accretions to knowledge. In its practice, it has evolved to meet the chang ing needs of society. Medical and dental practice will continue to evolve. Sound progress in the human relations of profes sional practice has always been an evolu tionary process. I do not foresee or fear any radical change in the methods of medical or den tal practice in this country if our profes sions recognize the needs of the people for
medical and dental care and take the nec essary steps to meet those needs. This, in my opinion, will necessitate a closer part nership between the public health agencies, the research institutions and the professions themselves. Governments everywhere have ac cepted new responsibilities for their in digent and for th6se whose low incomes make them medically indigent. The nec essities of life, food, shelter and clothing, have been an old concern of rulers; but, under democratic governments, this con cern is not considered largesse: it has been assumed as a responsibility. Similarly, so ciety accepts medical and dental care as one of the necessities of life. All of our plans for medical and dental care in the future must take into account the inherent right of every citizen to be able to secure the services which science has made it possible for our professions to give. In recent years, public funds have been used increasingly to provide not only for the prevention of disease, but also for the care of those unable to provide service for themselves. I hope the public con tinues to accept an increasing share of responsibility for our underprivileged groups. Responsibility for health, under our form of government, is shouldered pri marily by each community. How much of the burden should fall on the federal gov ernment and the state is a problemwhich must yield to the judgment of experience. There must be minimum standards of medical and dental care. In arresting dissease, including dental diseases, and in preventing the development of disease, society assumes an obligation which will pay dividends in the conservation of hu man resources. In my opinion, the necessary medical and dental services of the country can be furnished to the people without a fed eralized systemof medical or dental prac tice. The first interest of the Public Health Service is to prevent disease, whether physical, mental or dental. Dur-
Rule— G old Foil and Platinum-Centered Gold Foil
ing the past fifty years, we have worked out sound methods of cooperating with the states in the development of their health programs. This cooperation has not entailed a centralization of authority. The principle of grants-in-aid for public health under the Social Security Act in itself represents merely an extension of the traditional federal-state relationships in which there is a maximum of community responsibility, the maximum of local di rection for health programs which meet minimum standards applied by the fed eral government but created by the states. In working out this whole program of research, of prevention, better service for all, we need the full cooperation and lead ership of the dental profession through your national, state and local associations.
1783
I close with a paragraph fromRosenau : Preventive medicine dreams of a timewhen there shall be enough for all, and every man shall bear his share of labor in accordance with his ability, and every man shall possess sufficient for the needs of his body and the demands of health. These things heshall have as a matter of justice and not of charity. Pre ventive medicine dreams of a timewhenthere shall be no unnecessary suffering and no pre mature deaths; whenthe welfare of the people shall be our highest concern; when humanity and mercy shall replace greed and selfishness; and it dreams that all these things will be ac complished through the wisdom of man. Pre ventive medicine dreams of these things, not with the hope that we, individually, may par ticipate inthem, but with the joy that we may aid in their coming to those who shall live after us. When young men have vision the dreams of old men come true.
GOLD FOIL AND PLATINUM-CENTERED GOLD FOIL; METHODS OF CONDENSATION A REPORT OF CONTINUED INVESTIGATIONS-}By R. W. R u l e , * D.D.S., San Francisco, Calif. INCE the report of a year ago,1 pub methods of condensation. Special interest lished in April of this year, this in in the latter was promoted by the inven vestigation has been carried on, tion of a pneumatic condenser, which was primarily with a view to checking the re called to my attention in November of sults of work with heavier platinum-cen last year and which seemed worthy of tered gold foil as suggested in the earlier careful consideration. report. In addition to this, a further The time that it was possible to devote check has been made on the different to this work during a busy year has not been sufficient to make the investigation *A uthor’s note— This paper should be read in connection with the report published in T h e as complete as one would like, but the re J ou rn a l, April 19 37 , p. 58 3 . sults have been convincing, at least to the •(•Contribution from the Division o f Opera mind of the investigator. tive Dentistry in conjunction with the Division Only such reference will be made to the o f Physical Sciences, College o f Dentistry, U n i earlier report as is necessary for compari versity o f California. (Read before the Section on Operative D en sons. tistry, Materia M edica and Therapeutics at The same split steel die was used for the the Seventy-Ninth Annual Session o f the test specimens, and, in addition, cavities American Dental Association, Atlantic City, of approximately the same dimensions as N . J., July 1 3 , 1 9 3 7 .)
S
Jour. A .D .A . & D . Cos., V ol. 24, November 19 3 7
Earl
of
D erby,
who
dyed
in
Q ueen Elizabeth’s days, was famous for chirurgerie, bonesetting, and hospitalitie.
O records the diary of John Ward, a seventeenth century vicar of Stratford-on-Avon. That phrase with its medical flavor has an aptitude for this gathering. There is, in the first place, the warm hospitality of your welcome and my own personal friendship with many of you. But there is, beyond that, the warmth and hospitality which have marked all the relations of the American Dental Association with the United States Public Health Service. There is no group with which we have worked more happily than with yours. Yours were among the strongest shoulders put to the legislative wheel a few years ago when the Public Health Service was reor ganized on more effective lines. Your ac tive interest in the preventive aspects of your medical specialty places your philos ophy particularly close to that of those who work in public health. You have co operated with us actively in numerous studies and investigations. In the Public Health Service, the dental surgeon works in his rightful place as a commissioned officer with status equal and identical in every way to that of his medical and engi neering colleagues. I would emphasize that status of colleagueship. It was once customary, I be lieve, for a physician addressing a group of dentists to begin his remarks with a reference to Paul Revere. The reference was not to that gripping night when Paul peered through the mouth of the Charles
S
(Read at the Second General M eeting o f the Seventy-Ninth Annual Session of the American Dental Association, Atlantic City, N . J., July 13, I937-)
Jour. A .D .A . & D. Cos., V o l. 24, November 19 3 7
River to discover whether one or two of the cavities in the North Church tower would glow with gold, but to those later days when he was a dentist to the Boston brahmins and member of Boston’s first board of health. It was a good beginning for a physician. It gave him self-confidence before your profession. It served to remind him and his audience that medicine is a senior branch and that dentistry began as an in cident to other trades. And I shall not gainsay that many required confidence. For, as Dr. Oliver Wendell Holmes told Harvard’s first dental graduates, yours is “a profession in whose presence kings are silent, at whose command eloquence is struck dumb, and even the irresistible and irrepressible voice of woman is hushed in a brief interval of repose.” The physician, of course, in using the historical allusion was wont to ignore the fact that medicine, too, was once a child. Paul Revere and the Egyptians may have built their bridges with no thought of pathology. They may not have under stood the problem of decay or the minute organisms that are the parents of infec tion; but neither did the doctors of the day whose work as physicians had but re cently been divorced from other trades. “In King Richard the Second’s time, phy sicians and divines were not distinct pro fessions,” said that same John Ward. It had been but a century or so before Re vere that the physician and the barber went different but equally unscientific ways. The man who inserted an inlay without thought of an abscess was little different from the man who sutured a wound without knowledge of microbes. If John Greenwood, who constructed the I 778
Parran—Next Steps in Public Health
ivory, spring-controlled teeth of George Washington, was only an artificer, the doctors who bled him repeatedly till the “blood came slow and thick” leave even less for the admiration of posterity. Yes, if dentistry rode with Paul Revere in the past, the candid reader cannot escape the fact that medicine rode frequently with the fourth horseman. But I did not come to discuss history. Both medicine and dentistry are emerging froma past which, while earnest and hon orable, was frequently unscientific. Even now, we have done little more than scratch the surface of potential knowl edge. There is much unfinished business, in our sciences if we are to prolong life, to promote health and to add to the total of human happiness and prosperity. Our emphasis is shifting from cure, from alleviation of symptoms to prevention. Diseases of the teeth present one of the most promising fields for a program of prevention. It has been estimated that but a quarter of our population now re ceive adequate dental care. Tooth ail ments are next only to the common cold as the most frequent of our ills. Dentists over a period of two decades have most effectively impressed their pa tients with the need for regular care. The American who does not have his dental examination two or three times a year is apologetic; whereas, the American who never has a thorough general physicial examination all too frequently regards his lapse from medical observation as a sign of masculinity or strength. You have, without doubt, a strong cos metic urge as your ally in interesting the public in teeth. “There is no pearl in any royal crown for which a young queen would give one of her front incisors,” said Holmes. It is an advantage in propa ganda the physician does not have. If our hearts were, indeed, worn on our sleeves, one may suppose that heart disease would appear earlier for diagnosis. But what ever the reason for public consciousness of teeth, the result is there. Your patients
1779
come back. Your profession recognizes a responsibility on the part of the practi tioner to invite them to the periodic ex amination. R ELATIO N O F T H E P U B LIC H E A L T H SE R V IC E TO D EN T IST R Y
*
The work of the United States Public Health Service with relation to dentistry falls into a natural trichotomy. There is first the clinical work, the furnishing of dental service. There is, secondly, the public health work, the development of a program which will reduce the incidence of dental disease and bring existing dental disease to diagnosis and treatment. There is, finally, the extension of our knowledge of dental ill health through scientific re search. I shall consider themsuccessively. T R E A TM EN T
Treatment is furnished only to bene ficiaries of the United States Public Health Service. This includes merchant seamen, and the Coast Guard, who have been medical charges of the Service since its establishment in 1798. It includes lepers, those held at immigrant stations, inmates of federal penitentiaries and a few special groups. Full-time officers of the Service gave 698,743 treatments to 173,271 patients during the year 1936. We have taken the attitude that care of the patients in our charge involves skilled dental care no less than competent diag nosis and treatment are required in the other specialties of medicine. P U B LIC H E A L T H
One could not epitomize the change that has taken place in dentistry during the past sixty-five years more succinctly than by contrasting that previously cited Harvard commencement address of Dr. Holmes with the discussion in the den tal journals today. It was the mechanical wonders of replacement that enraptured the dentist in 1872. He drew an urbane contrast between the rateliers of the French and the “mineral teeth” which
1780
The Journal of the American Dental Association and The Dental Cosmos
America had brought to “greatest per fection.” “There are nine factories en gaged in their fabrication,” he boasted. “Compare the delicately tinted, exquisitely shaped porcelain incisors with those frightful palisades that used to play up and down like a portcullis in a manner terrifying to all beholders.” The modern emphasis on saving teeth, the fact that teeth have utilitarian uses essential to the health and happiness of the human animal, is hinted at only one point. Holmes quoted the sad complaint of Wal ter Savage Landor: “I have lost my mind,” cried the poet; “that I do not care so much about; but I have lost my teeth and I cannot eat.” Today, dentists fight to save teeth and to develop sound teeth. Health depart ments and school health services are or* ganized to ascertain the condition of children’s teeth and to give them prophy lactic care. Industrial medical services find that a dental clinic pays dividends in time saved and in increased efficiency. Not cosmetics, but economics has pre sented its brief for better dental care. It was the Social Security program which crystallized our economic interest in the public health. One must go back a little in history to trace that develop ment. When the President appointed a committee to consider ways and means of minimizing social insecurity, it was evi dent that the problem of preventable un employment and preventable disability due to disease were keys to the ultimate stability of the program. The late Edgar Sydenstricker headed the technical committee which dealt with medical care. Any national program of health security, he declared, should em phasize prevention of disease, and preven tion should take precedence over any efforts to distribute the costs of sickness or its consequences. From his recommendations grew those provisions of the act which relate to pub lic health. An appropriation of $8,000,000 a year was provided to assist states
and counties and other political subdi visions in establishing and maintaining adequate public health services, including the training of personnel. These funds are distributed among the states on a three fold basis: The population of the states, the special health problems of the state and the financial needs and resources. An additional $2,000,000 was authorized to extend the research work of the Pub lic Health Service. The precise programs in each state are not under any authoritative control of the United States Public Health Service or any federal agency. The act provides that before the regulations are issued govern ing the state allotments, conferences should be held with the states and terri torial health officers. These regulations apply with equal force to the dental pub lic health program and to all other public health developments under the act. The first conference of state health officers in 1935 drew up regulations as to the pur poses for which such funds might be ex pended. As I see it, the United States Public Health Service can exercise its best influ ence over this development by acting as a catalytic agent, bringing together, stimu lating into action, local public and private agencies throughout the land. It can re port facts; it can synthesize the work of others; it can operate the lighthouse on which local public health navigation must depend. I would dwell briefly on some of our recent work. Foremost, perhaps, is the work of oral health education. Dr. Frank C. Cady, dental surgeon of the Service, has recently prepared an outline of procedures in this field for the assistance of health officers and local groups. These are the principles which he emphasizes: That the dentist administering this activity for the health department have graduate training in public health methods; that his work shall be directed toward stimulatingand coordi nating the work of all agencies and indi viduals concerned : the dental profession,
Parran—Next Steps in Public Health
the medical profession, public health nurses, school teachers and those who will benefit from the program: the pre-school children, the school children and the adults of the community. There are two points which are empha sized in the contemplation of the Social Security Act. One is the local control over the development of the program. The other is that personnel shall be trained and high professional standards be main tained in order that local control may be thoroughly effective. In dealing with all groups who work under the Act, the Public Health Service seeks to develop the technics that will insure the success of that local control, and thus cooperation with the dental societies and the medical socie ties in coordinating the work is urged in considerable detail. In every state health department, there should be a dental division, and this divi sion should be charged with responsibility for developing this program. That was the recommendation of the Conference of Local and State Health Officers. Many states have established such offices. To meet the need for trained personnel, short intensive courses are being set up to train health officers, nurses and other personnel in the problems of the new program. Cer tain schools were designated as regional training centers by a majority vote of state health officers. They were selected for their special facilities for dealing with public health matters. The ultimate success of training and planning, however, must rest upon the completeness of our facts. Measurement must precede the draftsman’s pen. As to dental needs, we have such facts. Last year, the Public Health Service published a dental survey of school children, ages six to fourteen years, made in 1933-1934 under the direction of the late Dr. C. T. Messner. Data for tabulation were con tributed by more than 8,000 practicing dentists in twenty-six states. The published report of Dr. Messner’s survey is no light reading. It is nothing
1781
to read in the nonchalant comfort of a lounge chair. Of its 248 pages, 277 are the tabulated record of the findings of the 8,000 of your colleagues who examined the teeth of the school children in the twenty-six states surveyed. It is a record of dental caries in American school chil dren, of gingivitis, of extractions needed, of malocclusion. With its figures—and you can request it as Public Health Bulle tin No. 226—this survey provides state health authorities and your local societies with the ammunition for a campaign for better dental care. You will find it there county by county and town by town as a factual basis for needed action. R ESE A R C H
Salient in the fight against dental dis ease is the third field of our concern, re search. We must discover the causes of dental caries, we must find the factors in building sound and regular teeth and the things which will inhibit diseases of the teeth. Research has all too often been given over to the great dramatic things which kill and maim a few, while the things which sap the vitality of the million are ignored. As a consequence, tooth diseases which are merely common are not so well un derstood as they must be if we are to make real progress in reducing their incidence. It is in the field of research that the Pub lic Health Service can contribute a great deal to the dental profession. In research and as a clearing house for research, the Service makes one of its greatest contribu tions. One such project has already pro gressed to the point where it has produced results. You are, no doubt, familiar with the studies which H. Trendley Dean, den tal surgeon, has conducted in the problem of mottled enamel. The Service published in 1933 his study on the distribution of mottled enamel in the United States, which localized sixty-seven areas of high prevalence. The following year a report of laboratory experiments which showed the
1782
The Journal of the American Dental Association and The Dental Cosmos
effect of ingestion of various amounts of sodium fluoride on the teeth of white rats was published. Studies since that time in the special area of Texas and in the minimal threshold of mottled enamel have added to the accuracy of our knowl edge. These and the various experiments in the field of nutrition suggest that dental research may open new vistas in the chemical interpretation of human ills. There is one point to which I think your profession and this association should direct special attention. That is the funds for research. The amount of research which may be done will be limited, is bound to be limited, by the funds which are available. For dental diseases which are persistent rather than deadly, appro priating bodies have not always seen the wisdom of supplying funds for research. I hope it will be possible for the United States Public Health Service to extend its work with your research committees in stimulating and assisting research in uni versities and scientific institutions. We need, then, to extend our knowl edge of the factors which make for dental health. Hand in hand with this search for new knowledge must go the better appli cation of present knowledge, first to pre vent disease, and secondly to give needed care and treatment to all groups of the population. Each dentist needs to concern himself not only with the dental needs of the individual patient, but also with the dental needs of the whole community. Dentistry of today differs a great deal from that of Paul Revere’s day. Scien tifically it has evolved as the result of suc cessive accretions to knowledge. In its practice, it has evolved to meet the chang ing needs of society. Medical and dental practice will continue to evolve. Sound progress in the human relations of profes sional practice has always been an evolu tionary process. I do not foresee or fear any radical change in the methods of medical or den tal practice in this country if our profes sions recognize the needs of the people for
medical and dental care and take the nec essary steps to meet those needs. This, in my opinion, will necessitate a closer part nership between the public health agencies, the research institutions and the professions themselves. Governments everywhere have ac cepted new responsibilities for their in digent and for th6se whose low incomes make them medically indigent. The nec essities of life, food, shelter and clothing, have been an old concern of rulers; but, under democratic governments, this con cern is not considered largesse: it has been assumed as a responsibility. Similarly, so ciety accepts medical and dental care as one of the necessities of life. All of our plans for medical and dental care in the future must take into account the inherent right of every citizen to be able to secure the services which science has made it possible for our professions to give. In recent years, public funds have been used increasingly to provide not only for the prevention of disease, but also for the care of those unable to provide service for themselves. I hope the public con tinues to accept an increasing share of responsibility for our underprivileged groups. Responsibility for health, under our form of government, is shouldered pri marily by each community. How much of the burden should fall on the federal gov ernment and the state is a problemwhich must yield to the judgment of experience. There must be minimum standards of medical and dental care. In arresting dissease, including dental diseases, and in preventing the development of disease, society assumes an obligation which will pay dividends in the conservation of hu man resources. In my opinion, the necessary medical and dental services of the country can be furnished to the people without a fed eralized systemof medical or dental prac tice. The first interest of the Public Health Service is to prevent disease, whether physical, mental or dental. Dur-
Rule— G old Foil and Platinum-Centered Gold Foil
ing the past fifty years, we have worked out sound methods of cooperating with the states in the development of their health programs. This cooperation has not entailed a centralization of authority. The principle of grants-in-aid for public health under the Social Security Act in itself represents merely an extension of the traditional federal-state relationships in which there is a maximum of community responsibility, the maximum of local di rection for health programs which meet minimum standards applied by the fed eral government but created by the states. In working out this whole program of research, of prevention, better service for all, we need the full cooperation and lead ership of the dental profession through your national, state and local associations.
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I close with a paragraph fromRosenau : Preventive medicine dreams of a timewhen there shall be enough for all, and every man shall bear his share of labor in accordance with his ability, and every man shall possess sufficient for the needs of his body and the demands of health. These things heshall have as a matter of justice and not of charity. Pre ventive medicine dreams of a timewhenthere shall be no unnecessary suffering and no pre mature deaths; whenthe welfare of the people shall be our highest concern; when humanity and mercy shall replace greed and selfishness; and it dreams that all these things will be ac complished through the wisdom of man. Pre ventive medicine dreams of these things, not with the hope that we, individually, may par ticipate inthem, but with the joy that we may aid in their coming to those who shall live after us. When young men have vision the dreams of old men come true.
GOLD FOIL AND PLATINUM-CENTERED GOLD FOIL; METHODS OF CONDENSATION A REPORT OF CONTINUED INVESTIGATIONS-}By R. W. R u l e , * D.D.S., San Francisco, Calif. INCE the report of a year ago,1 pub methods of condensation. Special interest lished in April of this year, this in in the latter was promoted by the inven vestigation has been carried on, tion of a pneumatic condenser, which was primarily with a view to checking the re called to my attention in November of sults of work with heavier platinum-cen last year and which seemed worthy of tered gold foil as suggested in the earlier careful consideration. report. In addition to this, a further The time that it was possible to devote check has been made on the different to this work during a busy year has not been sufficient to make the investigation *A uthor’s note— This paper should be read in connection with the report published in T h e as complete as one would like, but the re J ou rn a l, April 19 37 , p. 58 3 . sults have been convincing, at least to the •(•Contribution from the Division o f Opera mind of the investigator. tive Dentistry in conjunction with the Division Only such reference will be made to the o f Physical Sciences, College o f Dentistry, U n i earlier report as is necessary for compari versity o f California. (Read before the Section on Operative D en sons. tistry, Materia M edica and Therapeutics at The same split steel die was used for the the Seventy-Ninth Annual Session o f the test specimens, and, in addition, cavities American Dental Association, Atlantic City, of approximately the same dimensions as N . J., July 1 3 , 1 9 3 7 .)
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Jour. A .D .A . & D . Cos., V ol. 24, November 19 3 7